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Yang X, Xu X, Li J, Song M, Sun H, Zhang H, Zhang X, Xu Y, Shi J. Management of infected bone defects of the femoral shaft by Masquelet technique: sequential internal fixation and nail with plate augmentation. BMC Musculoskelet Disord 2024; 25:552. [PMID: 39014409 PMCID: PMC11253414 DOI: 10.1186/s12891-024-07681-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 07/09/2024] [Indexed: 07/18/2024] Open
Abstract
BACKGROUND To evaluate the effectiveness of a sequential internal fixation strategy and intramedullary nailing with plate augmentation (IMN/PA) for bone reconstruction in the management of infected femoral shaft defects using the Masquelet technique. METHODS We performed a retrospective descriptive cohort study of 21 patients (mean age, 36.4 years) with infected bone defects of the femoral shaft treated by the Masquelet technique with a minimum follow-up of 18 months after second stage. After aggressive debridement, temporary stabilisation (T1) was achieved by an antibiotic-loaded bone cement spacer and internal fixation with a bone cement-coated locking plate. At second stage (T2), the spacer and the locking plate were removed following re-debridement, and IMN/PA was used as definitive fixation together with bone grafting. We evaluated the following clinical outcomes: infection recurrence, bone union time, complications, and the affected limb's knee joint function. RESULTS The median and quartiles of bone defect length was 7 (4.75-9.5) cm. Four patients required iterative debridement for infection recurrence after T1. The median of interval between T1 and T2 was 10 (9-19) weeks. At a median follow-up of 22 (20-27.5) months, none of the patients experienced recurrence of infection. Bone union was achieved at 7 (6-8.5) months in all patients, with one patient experiencing delayed union at the distal end of bone defect due to screws loosening. At the last follow-up, the median of flexion ROM of the knee joint was 120 (105-120.0)°. CONCLUSIONS For infected femoral shaft bone defects treated by the Masquelet technique, sequential internal fixation and IMN/PA for the reconstruction can provide excellent mechanical stability, which is beneficial for early functional exercise and bone union, and does not increase the rate of infection recurrence.
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Affiliation(s)
- Xiaoyong Yang
- Department of Orthopaedics, 920th Hospital of the Joint Logistics Support Force of the PLA, 212 Daguan Road, Kunming, 650032, China
| | - Xiaoyan Xu
- Department of Orthopaedics, 920th Hospital of the Joint Logistics Support Force of the PLA, 212 Daguan Road, Kunming, 650032, China
| | - Junyi Li
- Department of Orthopaedics, 920th Hospital of the Joint Logistics Support Force of the PLA, 212 Daguan Road, Kunming, 650032, China
| | - Muguo Song
- Department of Orthopaedics, 920th Hospital of the Joint Logistics Support Force of the PLA, 212 Daguan Road, Kunming, 650032, China
| | - Han Sun
- Department of Radiology, 920th Hospital of the Joint Logistics Support Force of the PLA, 212 Daguan Road, Kunming, 650032, China
| | - Hu Zhang
- Department of Orthopaedics, 920th Hospital of the Joint Logistics Support Force of the PLA, 212 Daguan Road, Kunming, 650032, China
| | - Xijiao Zhang
- Department of Orthopaedics, 920th Hospital of the Joint Logistics Support Force of the PLA, 212 Daguan Road, Kunming, 650032, China
| | - Yongqing Xu
- Department of Orthopaedics, 920th Hospital of the Joint Logistics Support Force of the PLA, 212 Daguan Road, Kunming, 650032, China
| | - Jian Shi
- Department of Orthopaedics, 920th Hospital of the Joint Logistics Support Force of the PLA, 212 Daguan Road, Kunming, 650032, China.
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Bowers KM, Anderson DE. Delayed Union and Nonunion: Current Concepts, Prevention, and Correction: A Review. Bioengineering (Basel) 2024; 11:525. [PMID: 38927761 PMCID: PMC11201148 DOI: 10.3390/bioengineering11060525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/12/2024] [Accepted: 05/17/2024] [Indexed: 06/28/2024] Open
Abstract
Surgical management of fractures has advanced with the incorporation of advanced technology, surgical techniques, and regenerative therapies, but delayed bone healing remains a clinical challenge and the prevalence of long bone nonunion ranges from 10 to 15% of surgically managed fractures. Delayed bone healing arises from a combination of mechanical, biological, and systemic factors acting on the site of tissue remodeling, and careful consideration of each case's injury-related, patient-dependent, surgical, and mechanical risk factors is key to successful bone union. In this review, we describe the biology and biomechanics of delayed bone healing, outline the known risk factors for nonunion development, and introduce modern preventative and corrective therapies targeting fracture nonunion.
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Affiliation(s)
| | - David E. Anderson
- Large Animal Clinical Sciences, University of Tennessee College of Veterinary Medicine, 2407 River Dr., Knoxville, TN 37996-4550, USA;
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Devendra A, Patra SK, Velmurugesan P, Zackariya M, Ramesh P, Arun Kamal C, Dheenadhayalan J, Rajasekaran S. Results of a simple treatment protocol for aseptic femoral shaft nonunion in 330 patients. Injury 2024; 55:111412. [PMID: 38341997 DOI: 10.1016/j.injury.2024.111412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/21/2024] [Accepted: 01/27/2024] [Indexed: 02/13/2024]
Abstract
INTRODUCTION Our primary aim of the study was to assess the results of a treatment protocol for aseptic femoral shaft nonunion treated by three techniques - Exchange Nailing (EN), Plate Augmentation (PA), and Exchange Nailing combined with Plate augmentation (NP). The secondary objective was to assess the radiological outcome, duration of surgery (DOS) and need for blood transfusion (BT) in all the three groups. MATERIALS AND METHODS We analyzed 330 patients treated for AFNU between Jan 2007 and Dec 2019. Using a simple treatment algorithm, EN, PA and NP were performed in 24,183 and 123 patients respectively. Patients in all the three groups were assessed for radiological-union (union rate and time to union), DOS and BT. RESULTS Of these 330 patients, 327 (99 %) patients achieved radiological union at a mean duration of 6.07 months. Union rate is highest with NP followed by PA and EN. The union rate in patients with NP, PA and EN were 100 %, 99.5 % and 91.7 % respectively (p < 0.01). Time to union was lowest for NP followed by PA and EN (p < 0.001).The mean time to union for NP, PA and EN were 3.76, 7.2and 9.21 months respectively (p < 0.001). The mean DOS in minutes for NP, EN and PA was 107, 94 and 82 respectively (p < 0.01). The mean need for BT in the form of packed red blood cells for NP, PA and EN were 1.95, 1.87 and 1.38 units respectively (p < 0.01). CONCLUSION Following a simple algorithm to decide treatment protocol on a case-to case basis helps to achieve good results in an optimal time period. When compared with EN and PA, NP is associated with 100 % union rate with least time to union making NP a reasonably effective procedure with a very high success rate. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Agraharam Devendra
- Department of Orthopaedics and Trauma, Ganga Medical Centre & Hospitals Pvt Ltd, Tamil Nadu, India.
| | - Sudipta Kumar Patra
- Department of Orthopaedics and Trauma, Ganga Medical Centre & Hospitals Pvt Ltd, Tamil Nadu, India
| | - P Velmurugesan
- Department of Orthopaedics and Trauma, Ganga Medical Centre & Hospitals Pvt Ltd, Tamil Nadu, India
| | - Mohd Zackariya
- Department of Orthopaedics and Trauma, Ganga Medical Centre & Hospitals Pvt Ltd, Tamil Nadu, India
| | - P Ramesh
- Department of Orthopaedics and Trauma, Ganga Medical Centre & Hospitals Pvt Ltd, Tamil Nadu, India
| | - Chandramohan Arun Kamal
- Department of Orthopaedics and Trauma, Ganga Medical Centre & Hospitals Pvt Ltd, Tamil Nadu, India
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Bianco Prevot L, Nannini A, Mangiavini L, Bobba A, Buzzi S, Sinigaglia F, Peretti G. What Is the Best Treatment of the Femoral Shaft Nonunion after Intramedullary Nailing? A Systematic Review. Life (Basel) 2023; 13:1508. [PMID: 37511883 PMCID: PMC10381168 DOI: 10.3390/life13071508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/30/2023] [Accepted: 07/03/2023] [Indexed: 07/30/2023] Open
Abstract
Nonunion (NU) is one of the most feared complications of femoral shaft fracture treatment. Femoral shaft fracture treatment is often linked with poor bone stock and reduced bone metabolism. In this paper, the goal is to carefully analyze the best treatment options for patients who developed nonunion after the intramedullary nailing of a femoral shaft fracture. A systematic review of the literature available in the PubMed, EMBASE and Cochran library databases was carried out, and 16 studies were included. Exclusion criteria included case reports and case series that do not have data about clinical outcomes or functional outcomes and included fewer than 10 patients. The reviewed data provide evidence for very good results about the treatment of this pathology with exchanging intramedullary nails or the implantation of a plate and screws (general healing rate of 96.3%). Moreover, the data support the utilization of autologous bone graft in order to stimulate the healing process. In conclusion, the choice between these two types of treatment must be guided by the type of pseudarthrosis that the patient presents. Additionally, bone grafting or growth factors promote bone regenerative processes, especially in patients with oligo-atrophic pseudoarthrosis.
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Affiliation(s)
- Luca Bianco Prevot
- IRCCS Galeazzi-S. Ambrogio Institute, EUORR University Equip of Regenerative and Reconstructive Orthopedics, Via Cristina Belgioioso 173, 20157 Milan, Italy
| | - Alessandra Nannini
- IRCCS Galeazzi-S. Ambrogio Institute, EUORR University Equip of Regenerative and Reconstructive Orthopedics, Via Cristina Belgioioso 173, 20157 Milan, Italy
| | - Laura Mangiavini
- IRCCS Galeazzi-S. Ambrogio Institute, EUORR University Equip of Regenerative and Reconstructive Orthopedics, Via Cristina Belgioioso 173, 20157 Milan, Italy
| | - Andrea Bobba
- IRCCS Galeazzi-S. Ambrogio Institute, EUORR University Equip of Regenerative and Reconstructive Orthopedics, Via Cristina Belgioioso 173, 20157 Milan, Italy
| | - Sara Buzzi
- IRCCS Galeazzi-S. Ambrogio Institute, EUORR University Equip of Regenerative and Reconstructive Orthopedics, Via Cristina Belgioioso 173, 20157 Milan, Italy
| | - Federico Sinigaglia
- IRCCS Galeazzi-S. Ambrogio Institute, EUORR University Equip of Regenerative and Reconstructive Orthopedics, Via Cristina Belgioioso 173, 20157 Milan, Italy
| | - Giuseppe Peretti
- IRCCS Galeazzi-S. Ambrogio Institute, EUORR University Equip of Regenerative and Reconstructive Orthopedics, Via Cristina Belgioioso 173, 20157 Milan, Italy
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Walcher MG, Day RE, Gesslein M, Bail HJ, Kuster MS. Augmentative Plating versus Exchange Intramedullary Nailing for the Treatment of Aseptic Non-Unions of the Femoral Shaft-A Biomechanical Study in a Sawbone TM Model. J Pers Med 2023; 13:jpm13040650. [PMID: 37109036 PMCID: PMC10142865 DOI: 10.3390/jpm13040650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/06/2023] [Accepted: 04/08/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Non-unions after intramedullary nailing of femoral shaft fractures are a significant problem. Treatment options such as augmenting with plates or exchange nailing have been proposed. The ideal treatment remains controversial. METHODS Augmentative plating using a 4.5 mm LCP or a 3.2 mm LCP leaving the nail in situ was tested biomechanically and compared to exchange intramedullary nailing in a SawboneTM model of a femoral shaft non-union. RESULTS The difference of fracture gap motion in axial testing was small. In rotational testing, the exchange nail allowed for the largest amount of motion. The 4.5 mm augmentative plate was the most stable construct in all loading conditions. CONCLUSIONS Augmentative plating using a 4.5 mm LCP plate while leaving the nail in situ is biomechanically superior to exchange intramedullary nailing. A small fragment 3.2 mm LCP is undersized and does not reduce fracture motion sufficiently in a femoral shaft non-union.
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Affiliation(s)
- Matthias Georg Walcher
- OC Würzburg, Oeggstr. 3, 97070 Würzburg, Germany
- Department of Orthopedics and Traumatology, Paracelsus Medical University, Breslauer Straße 201, 90471 Nuremberg, Germany
| | - Robert E Day
- Health Technology Management Unit, Royal Perth Hospital, University of Western Australia, 197 Wellington Street, Perth 6000, Australia
| | - Markus Gesslein
- Department of Orthopedics and Traumatology, Paracelsus Medical University, Breslauer Straße 201, 90471 Nuremberg, Germany
| | - Hermann Josef Bail
- Department of Orthopedics and Traumatology, Paracelsus Medical University, Breslauer Straße 201, 90471 Nuremberg, Germany
| | - Markus S Kuster
- Perth Orthopaedic Sports Medicine Centre, The University of Western Australia, 31 Outram Street, Perth 6005, Australia
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Çimen O, Öner A, Köksal A, Dırvar F, Mert M, Kargın D. A comparison of exchange nailing and plate augmentation over a retained intramedullary nail in aseptic oligotrophic and atrophic femoral shaft pseudoarthrosis. Jt Dis Relat Surg 2023; 34:121-129. [PMID: 36700273 PMCID: PMC9903120 DOI: 10.52312/jdrs.2023.788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 11/22/2022] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES This study aims to evaluate the success of plate augmentation over a retained intramedullary nail (IMN) against exchange nailing performed with autologous bone grafting in oligotrophic and atrophic pseudoarthrosis of the femoral shaft. PATIENTS AND METHODS Between May 2005 and October 2020, a total of 42 of 56 patients (28 males, 14 females; mean age: 47.3±17.2 years; range, 19 to 84 years) with aseptic atrophic or oligotrophic femoral nonunion were retrospectively analyzed. The patients, 20 were operated with plate over a retained IMN, and the rest (n=22) by exchange nailing. Data including demographic and clinical characteristics of the patients, treatment success, duration of surgery, blood loss during surgery, infection rates, length of hospital stay, time to bridging of the nonunion site, and time to obliteration of the fracture line (solid union) were recorded. RESULTS The mean follow-up was 23.8±20.4 (range, 12 to 96) months in the plate over an IMN group and 34.7±27.4 (range, 12 to 90) months in the exchange nailing group. At the final follow-up, solid union occurred in all of the patients in the plate augmentation over a retained IMN group, and 21 of 22 (95.45%) patients in the exchange nailing group. Blood loss during surgery was significantly less in the plate augmentation over IMN group (p=0.027). There was no statistically significant difference in the other variables between the two groups (p>0.05). CONCLUSION Our study results demonstrate that plate over a retained IMN is effective as exchange nailing in the surgical treatment of oligotrophic and atrophic pseudoarthrosis of the femoral shaft. However, it can be speculated that plate application over IMN is more advantageous in terms of blood loss during surgery.
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Affiliation(s)
- Osman Çimen
- Metin Sabancı Baltalimanı Kemik Hastalıkları Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, Araştırma Hastanesi, 34470 Sarıyer, İstanbul, Türkiye.
| | - Ali Öner
- Department of Orthopedics and Traumatology, Ministry of Health Metin Sabancı Baltalimanı Bone and Joint Diseases Training and Research Hospital, İstanbul, Türkiye
| | - Alper Köksal
- Department of Orthopedics and Traumatology, Ministry of Health Metin Sabancı Baltalimanı Bone and Joint Diseases Training and Research Hospital, İstanbul, Türkiye
| | - Ferdi Dırvar
- Department of Orthopedics and Traumatology, Ministry of Health Metin Sabancı Baltalimanı Bone and Joint Diseases Training and Research Hospital, İstanbul, Türkiye
| | - Muhammed Mert
- Department of Orthopedics and Traumatology, Ministry of Health Metin Sabancı Baltalimanı Bone and Joint Diseases Training and Research Hospital, İstanbul, Türkiye
| | - Deniz Kargın
- Department of Orthopedics and Traumatology, Ministry of Health Metin Sabancı Baltalimanı Bone and Joint Diseases Training and Research Hospital, İstanbul, Türkiye
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van Trikt CH, Donders JCE, Klinger CE, Wellman DS, Helfet DL, Kloen P. Operative treatment of nonunions in the elderly: Clinical and radiographic outcomes in patients at minimum 75 years of age. BMC Geriatr 2022; 22:985. [PMID: 36539691 PMCID: PMC9764700 DOI: 10.1186/s12877-022-03670-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Limited information exists on nonunion treatment in the elderly. This retrospective study evaluates whether results of operative treatment of nonunion of the humerus or femur in patients aged ≥ 75 years are comparable to those in younger patients. METHODS We identified patients age ≥ 75 years with a nonunion of humerus or femur treated with open reduction and internal fixation. The Non-Union Scoring System was calculated. Complications, clinical outcome, and radiographic findings were assessed. Primary endpoint was nonunion healing. A literature review compared time to healing of humeral and femoral nonunion in younger populations. RESULTS We identified 45 patients treated for a nonunion of humerus or femur with > 12 months follow-up. Median age was 79 years (range 75-96). Median time to presentation was 12 months (range 4-127) after injury, median number of prior surgeries was 1 (range 0-4). Union rate was 100%, with median time to union 6 months (range 2-42). Six patients underwent revision for persistent nonunion and healed without further complications. CONCLUSIONS Using a protocol of debridement, alignment, compression, stable fixation, bone grafting and early motion, patients aged 75 years or older can reliably achieve healing when faced with a nonunion of the humerus or femur. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Clinton H. van Trikt
- grid.509540.d0000 0004 6880 3010Department of Orthopedic Surgery and Sports Medicine, Amsterdam University Medical Center, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Johanna C. E. Donders
- grid.509540.d0000 0004 6880 3010Department of Orthopedic Surgery and Sports Medicine, Amsterdam University Medical Center, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Craig E. Klinger
- grid.5386.8000000041936877XOrthopaedic Trauma Service, Hospital for Special Surgery and New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY USA
| | - David S. Wellman
- grid.260917.b0000 0001 0728 151XOrthopaedic Trauma Service, Westchester Medical Center, New York Medical College, Valhalla, NY USA
| | - David L. Helfet
- grid.5386.8000000041936877XOrthopaedic Trauma Service, Hospital for Special Surgery and New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY USA
| | - Peter Kloen
- grid.509540.d0000 0004 6880 3010Department of Orthopedic Surgery and Sports Medicine, Amsterdam University Medical Center, Amsterdam Movement Sciences, Amsterdam, The Netherlands
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Lu Y, Sun L, Wang Q, Ren C, Xu Y, Ye H, Li M, Xue H, Huang Q, Li Z, Zhang K, Ma T. Osteoperiosteal decortication and bone grafting combined with wave plating for femoral shaft aseptic atrophic nonunion after intramedullary nailing. J Int Med Res 2022; 50:3000605221139667. [PMID: 36447128 PMCID: PMC9716611 DOI: 10.1177/03000605221139667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVE Femoral shaft nonunion after intramedullary nailing fixation remains a challenge for orthopedic surgeons. This study evaluated osteoperiosteal decortication and iliac bone grafting combined with wave plating as a treatment for aseptic atrophic nonunion of the femoral shaft after intramedullary nailing. METHODS The study included 22 patients (two female, 20 male; mean age 40.8 years [range, 19-61]) with aseptic atrophic nonunion of the femoral shaft who underwent osteoperiosteal decortication and iliac bone grafting combined with wave plating between January 2016 and January 2020. Cases with infected nonunion, hypertrophic nonunion, and nonunion after plate osteosynthesis were excluded. Clinical outcomes were assessed retrospectively using the Samantha X-ray and Paley scale scores. RESULTS The mean follow-up period was 18.8 months (range, 12-35). Bone union was achieved in all patients. The average clinical healing time was 5.7 months (range, 3-14). The mean Samantha X-ray score was 5.7 ± 0.45 and the Paley scores indicated excellent or good clinical results in all cases. One patient developed sterile wound leakage that resolved after a dressing change. CONCLUSIONS Osteoperiosteal decortication and bone grafting combined with wave plating is an excellent treatment for aseptic atrophic nonunion of the femoral shaft after intramedullary nailing.
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Affiliation(s)
- Yao Lu
- Department of Orthopaedic Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Liang Sun
- Department of Orthopaedic Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Qian Wang
- Department of Orthopaedic Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Cheng Ren
- Department of Orthopaedic Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Yibo Xu
- Department of Orthopaedic Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Haobo Ye
- Xi’an Medical University, Xi’an, Shaanxi Province, China
| | - Ming Li
- Department of Orthopaedic Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Hanzhong Xue
- Department of Orthopaedic Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Qiang Huang
- Department of Orthopaedic Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Zhong Li
- Department of Orthopaedic Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Kun Zhang
- Department of Orthopaedic Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Teng Ma
- Department of Orthopaedic Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi Province, China,Teng Ma, Department of Orthopaedic Surgery, Honghui Hospital, Xi’an Jiaotong University, 555 Youyi East Road, Xi’an, Shaanxi Province 710054, China.
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9
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Wu T, Zhang W, Chang Z, Zhu Z, Sun L, Tang P, Chen H. Augmented Stability in Leaving Original Internal Fixation with Multidimensional Cross Locking Plate through Mini-Open Femoral Anterior Approach for Aseptic Femoral Shaft Nonunion: A Retrospective Cohort Study. Orthop Surg 2022; 15:169-178. [PMID: 36411511 PMCID: PMC9837237 DOI: 10.1111/os.13581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 10/05/2022] [Accepted: 10/11/2022] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Aseptic femoral shaft nonunion constitutes approximately 1%-10% of all femoral shaft fractures treated with intramedullary nail (IMN) fixation, possibly attributable to the lack of anti-rotational stability. Although a lateral locking plate (LP) with retainment of original IMN has shown the most success, lateral LP inflicts significant surgical trauma on patients. Therefore, the Multidimensional Cross Locking Plate (MDC-LP) was designed based on a mini-open femoral anterior approach. We aim to report and compare the technical aspects and clinical outcomes of using anterior MDC-LP or lateral LP with retention of original IMN for the treatment of aseptic femoral shaft nonunion. METHODS In this single center retrospective cohort study, records of 49 patients who had undergone revision of femoral shaft aseptic nonunion with anterior MDC-LP or lateral LP while retaining the original IMN from January 2015 to October 2019 were retrospectively reviewed. Information on patients' demographics, clinical data, and surgical outcomes were gathered and analyzed. X-ray and CT scans were used for bone union evaluation and the lower extremity functional scale (LEFS) was used for follow-up functional evaluation. For quantitative data, the Student's t-test was used if the data were normally distributed. The Mann-Whitney U-test was used for non-normally distributed data. For qualitative data, the Chi-square test was used for comparisons. RESULTS Twenty-seven patients were treated with anterior MDC-LP, and 22 patients were treated with lateral LP. There are no significant differences in age, sex, BMI, time since initial femoral shaft fracture, initial fracture type (close/open), nonunion type, or nonunion location between patients' group. Among patients treated with anterior MDC-LP, an average of 2-months advantage in time to union was observed (4.09 months vs. 6.8 months in the lateral LP group: P = 0.000), smaller incision was required for MDC-LP installment (7.7 cm vs 17.1 cm in lateral LP group: P = 0.000). CONCLUSIONS For the treatment of aseptic femoral shaft nonunion with retainment of original IMN, anterior MDC-LP via mini-open femoral anterior approach described in this study is a better option than lateral LP for achieving faster bone union and satisfactory functional outcome with less surgical trauma.
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Affiliation(s)
- Taoguang Wu
- Department of Orthopedic Surgerythe fourth medical center, Chinese PLA General hospitalBeijingChina
| | - Wei Zhang
- School of Sports EngineeringBeijing Sport UniversityBeijingChina
| | - Zuhao Chang
- Department of Orthopedic Surgerythe fourth medical center, Chinese PLA General hospitalBeijingChina
| | - Zhengguo Zhu
- Department of Orthopedic Surgerythe fourth medical center, Chinese PLA General hospitalBeijingChina
| | - Lijun Sun
- Department of Orthopedic Surgerythe fourth medical center, Chinese PLA General hospitalBeijingChina
| | - Peifu Tang
- Department of Orthopedic Surgerythe fourth medical center, Chinese PLA General hospitalBeijingChina
| | - Hua Chen
- Department of Orthopedic Surgerythe fourth medical center, Chinese PLA General hospitalBeijingChina
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10
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Perisano C, Cianni L, Polichetti C, Cannella A, Mosca M, Caravelli S, Maccauro G, Greco T. Plate Augmentation in Aseptic Femoral Shaft Nonunion after Intramedullary Nailing: A Literature Review. BIOENGINEERING (BASEL, SWITZERLAND) 2022; 9:bioengineering9100560. [PMID: 36290528 PMCID: PMC9598798 DOI: 10.3390/bioengineering9100560] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/11/2022] [Accepted: 10/13/2022] [Indexed: 11/05/2022]
Abstract
Background: Femoral shaft fractures (FSFs) are a frequent injury in traumatology for which intramedullary nailing (IMN) is considered the gold standard treatment. Nonunion (NU) is one of the most frequent complications in FSF treated with IMN, with a percentage from 1.1% to 14%. Plate augmentation (PA), the addition of a compression plate and screws, with or without bone graft has been described as an effective option for the treatment of NU, improving the biomechanical conditions at the fracture site. The aim of this review was to analyze the literature relating to the use of PA in NU after IMN in FSFs to assess the efficacy of the technique. Methods: An electronic search on PubMed, Google Scholar, and Web of Science was conducted to search for all studies concerning PA of femoral shaft NUs after IMN. Results: Twenty-four studies were included in the review comprising a total of 502 patients with a mean age of 39.5 years. Of these, 200 hundred patients had atrophic pseudoarthrosis and 123 had hypertrophic pseudoarthrosis, while in 179, the type of pseudoarthrosis was not reported. The most frequently used plate for PA was the dynamic compression plate (DCP); in 87.1% of the cases, the authors added a bone graft to the plate fixation. In 98.0% of the patients, a complete bone union was achieved in a mean time of 5.8 ± 2.12 months. Conclusion: The patients treated with PA included in this review showed a good rate of consolidation in the femoral shaft NUs, with good functional recovery and a low incidence of complications.
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Affiliation(s)
- Carlo Perisano
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Trauma Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Luigi Cianni
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Trauma Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Orthopedics and Trauma Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Chiara Polichetti
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Trauma Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Orthopedics and Trauma Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Adriano Cannella
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Trauma Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Orthopedics and Trauma Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Massimiliano Mosca
- IRCCS Istituto Ortopedico Rizzoli—U.O.C. II Clinic of Orthopaedics and Traumatology, 40136 Bologna, Italy
| | - Silvio Caravelli
- IRCCS Istituto Ortopedico Rizzoli—U.O.C. II Clinic of Orthopaedics and Traumatology, 40136 Bologna, Italy
| | - Giulio Maccauro
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Trauma Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Orthopedics and Trauma Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Tommaso Greco
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Trauma Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Orthopedics and Trauma Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Correspondence: ; Tel.: +39-3807582118
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Mohamed MA, Noaman HH, Soroor YO, Elsayed M. Plate augmentation and bone grafting in treatment of femoral shaft nonunion initially fixed by intramedullary nail. SICOT J 2022; 8:19. [PMID: 35608412 PMCID: PMC9128607 DOI: 10.1051/sicotj/2022020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 05/01/2022] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION This study aims to evaluate the results of plate augmentation and bone grafting without removing the nail in the treatment of nonunited, nailed femoral shaft fractures. METHODS Twenty patients with atrophic nonunion femoral shaft fractures initially fixed by intramedullary nail were treated by augmentation plating and iliac bone graft with retention of the nail. Patients were evaluated at regular intervals using an X-ray and Wu scoring system, which assesses clinical and radiological signs of healing. RESULTS All 20 patients achieved bony union at a mean time of 4.9 months (3-8 months). According to Wu's score, 12 cases showed excellent results, and 8 cases obtained good results with no complications recorded. CONCLUSION augmentation plating and iliac bone graft provide a good and safe method of treatment of previously nailed and non-united femoral shaft fractures. LEVEL OF EVIDENCE Level 4; Case Series.
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Affiliation(s)
| | - Hassan H. Noaman
- Orthopaedic Department, Sohag University Hospital 82524 Sohag Egypt
| | - Yasser O. Soroor
- Orthopaedic Department, Sohag University Hospital 82524 Sohag Egypt
| | - Moustafa Elsayed
- Orthopaedic Department, Sohag University Hospital 82524 Sohag Egypt
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12
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Pasque CB, Pappas AJ, Cole Jr CA. Intramedullary bone pedestal formation contributing to femoral shaft fracture nonunion: A case report and review of the literature. World J Orthop 2022; 13:528-537. [PMID: 35633740 PMCID: PMC9124995 DOI: 10.5312/wjo.v13.i5.528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 11/28/2021] [Accepted: 04/25/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Femoral shaft fracture is a commonly encountered orthopedic injury that can be treated operatively with a low overall delayed/nonunion rate. In the case of delayed union after antegrade or retrograde intramedullary nail fixation, fracture dynamization is often attempted first. Nonunion after dynamization has been shown to occur due to infection and other aseptic etiologies. We present a unique case of diaphyseal femoral shaft fracture nonunion after dynamization due to intramedullary cortical bone pedestal formation at the distal tip of the nail.
CASE SUMMARY A 37-year-old male experienced a high-energy trauma to his left thigh after coming down hard during a motocross jump. Evaluation was consistent with an isolated, closed, left mid-shaft femur fracture. He was initially managed with reamed antegrade intramedullary nail fixation but had continued thigh pain. Radiographs at four months demonstrated no evidence of fracture union and failure of the distal locking screw, and dynamization by distal locking screw removal was performed. The patient continued to have pain eight months after the initial procedure and 4 mo after dynamization with serial radiographs continuing to demonstrate no evidence of fracture healing. The decision was made to proceed with exchange nailing for aseptic fracture nonunion. During the exchange procedure, an obstruction was encountered at the distal tip of the failed nail and was confirmed on magnified fluoroscopy to be a pedestal of cortical bone in the canal. The obstruction required further distal reaming. A longer and larger diameter exchange nail was placed without difficulty and without a distal locking screw to allow for dynamization at the fracture site. Post-operative radiographs showed proper fracture and hardware alignment. There was subsequently radiographic evidence of callus formation at one year with subsequent fracture consolidation and resolution of thigh pain at eighteen months.
CONCLUSION The risk of fracture nonunion caused by intramedullary bone pedestal formation can be mitigated with the use of maximum length and diameter nails and close follow up.
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Affiliation(s)
- Charles B Pasque
- Department of Orthopaedic Surgery and Rehabilitation, University of Oklahoma College of Medicine, Oklahoma City, OK 73104, United States
| | - Alexander J Pappas
- Department of Orthopaedic Surgery and Rehabilitation, University of Oklahoma College of Medicine, Oklahoma City, OK 73104, United States
| | - Chad A Cole Jr
- University of Colorado School of Medicine, Aurora, CO 80045, United States
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Gönder N, Demir İH, Öğümsöğütlü E, Kılınçoğlu V. Collagen/Nano-hydroxyapatite Composite Scaffold Application with Exchange Reamed Nailing Accelerates Bone Union and Improves Quality of Life in Atrophic Femoral Shaft Nonunions: A Retrospective Comparative Study. Indian J Orthop 2021; 56:412-420. [PMID: 35251504 PMCID: PMC8854517 DOI: 10.1007/s43465-021-00545-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 10/10/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Our aim in this study was to evaluate the effect of exchange intramedullary nailing in femoral shaft atrophic nonunions and the use of collagen/nano-hydroxyapatite composite scaffold applied in addition to the cancellous iliac crest autograft on the union, return to work, and quality of life. MATERIALS AND METHODS Fifty-four patients with an atrophic nonunion in the isthmic region of the femoral shaft were included in the study. The patients were divided into two groups. Group A consisted of 24 patients who underwent collagen/nano-hydroxyapatite composite scaffold in addition to exchange intramedullary nailing and iliac autograft, while group B consisted of 30 patients without scaffold. Short Form-36 (SF-36) questionnaire scores, union rates, time to union, return to work were complications were compared. RESULTS Mean age of patients was 47.5 ± 14.1. The mean follow-up period was 3.56 ± 1.88 years. There was no statistically significant difference between Group A and B in terms of age, gender, smoking and alcohol use, and trauma mechanism. Time to union and return to work were statistically significantly shorter in Group A than in Group B (p = 0.004, p = 0.001). All of the SF-36 survey scores at month six were better in Group A. In the first year, mental health and general health perception were still statistically better in group A (p = 0.009, p = 0.008). CONCLUSION In the treatment of atrophic nonunions of the femoral shaft isthmic region, the use of collagen/nano-hydroxyapatite composite scaffolds together with exchange intramedullary nailing affects the union positively. This positive effect also brings about earlier return to work and better quality of life.
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Affiliation(s)
- Nevzat Gönder
- Department of Orthopaedics and Traumatology, T.C. Ministry of Health Islahiye State Hospital, 27800 Gaziantep, Turkey
| | - İbrahim Halil Demir
- Department of Orthopaedics and Traumatology, Gaziantep University Faculty of Medicine, 27310 Gaziantep, Turkey
| | - Erman Öğümsöğütlü
- Department of Orthopaedics and Traumatology, Gaziantep University Faculty of Medicine, 27310 Gaziantep, Turkey
| | - Volkan Kılınçoğlu
- Department of Orthopaedics and Traumatology, Gaziantep University Faculty of Medicine, 27310 Gaziantep, Turkey
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Fracture nonunion in long bones: A literature review of risk factors and surgical management. Injury 2021; 52 Suppl 2:S3-S11. [PMID: 33221036 DOI: 10.1016/j.injury.2020.11.029] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 11/06/2020] [Accepted: 11/10/2020] [Indexed: 02/02/2023]
Abstract
Nonunion following a long bone fracture causes considerable morbidity when it occurs. Risk factors depend on specific fractures but there is a complex interplay of injury severity, comorbidities, patient medication and infection. The majority of nonunions occur after long bone fractures with the tibia, femur, forearm, humerus and clavicle predominating. Despite interest in the biological augmentation of fracture healing, the majority of nonunions can be effectively managed with conventional surgical techniques. In this review we present a review of risk factors for nonunion and the outcome following surgical management.
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